User:Doc Tropics/United States health reform under Clinton

Bill Clinton, in his term from 1993 to 2001 was, like all presidents, charged with dealing with health reform. But despite all his efforts, he was unable to develop a fully transparent and simplified plan.

Knowing that the middle class was the main addressee of his plan, Clinton declared his top priorities to be for "those who do the work, pay the taxes, raise the kids, and play by the rules". His health-care reform plan was developed by some of the largest private insurers (Aetna, Prudential, and Travelers), who wanted to manage the delivery of health care along with paying for it. Large corporations, wanting to reduce cost through managed care and also wanting to shift some burden of cost to smaller companies, joined the interested parties. These corporations included General Electric Company, General Motors Corporation and Caterpillar.

Background
At the time of Clinton's election health reform seemed possible, given strong Democratic political capital in Congress (a democratic majority), and rising public support. The Democratic Congress would have been in favor of an agenda pertaining to public welfare and equality. Clinton, however, was unable to develop a clear and transparent national health-insurance plan. With Americans expecting reform, Clinton relied on his speechwriting team to develop a comprehensive health-care reform plan. However he rejected the plan just one day before his speech to a joint session of Congress concerning the future of health care. The final version of the speech briefly vaguely outlined how Clinton would implement national health insurance but left many questions unanswered. Ambiguities of the plan, including the finance of such reform, limited the credibility and efficiency of such reform.

Clinton also could not make health care a top priority for Americans. During his campaign, citizens ranked health care third behind the economy and the national deficit. In addition, Clinton failed to convince Americans to support his plan of managed competition. Opposition from powerful interest groups also hurt Clinton's chances of reforming the current health-care system.

Origins of the call for reform
Until the early 1990s, the US health care system was dominated by traditional indemnity insurance, fee-for-service payment, free choice of doctors who were mainly in solo or small group practices, and third-party payment. Americans had become used to top-quality care without having to pay the bill. This set-up led to a large problem of moral hazard which increased the cost of health care tremendously. With no central government organization to moderate costs, US companies began to complain that health-care costs put them at a competitive disadvantage compared to foreign competitors. Many large companies became more involved in overseeing employee health-care costs by self-insuring or enrolling their employees in a managed-care system. However, the late 1980s and early 1990s saw the rise and fall of the idea of managed care. While in 1980 few employers viewed health-care costs as a major problem, by the end of the decade that was no longer the prevailing view.

Rising health-care costs became an extremely serious issue in the 1990s. During the 1980s, median household incomes grew by $1500 while health-care costs grew by $1400. According to some estimates, one out of every seven dollars of goods and services produced in America was being spent on health care. Without insurance only the wealthy could afford health care, yet thirty seven million people, or 15% of the population, did not have insurance. In addition, government officials were worried that the rising costs would have a detrimental effect on the national debt and limit the amount of money available for other government programs (Johnson and Broder 62). Therefore, both Democrats and Republicans agreed that the health-care system needed to be reformed in order to provide greater security to citizens.

However, the issue would probably not have been brought to the forefront but for the 1991 off-term special election in Pennsylvania following the sudden death of Senator John Heinz. Pennsylvania's former Attorney General, Richard Thornburg, was widely expected to win. His challenger was Democrat Harris Wofford, who ran far behind in the polls and brought up the issue of health care reform as a "nothing to lose" issue. He recovered from a double digit deficit in the polls to win the senatorial election, putting health care reform on the national agenda.

Although previous efforts to impose universal health insurance had failed, Americans were now "experiencing a troubling new sense of vulnerability". During the 1990s, a large economic recession resulted in the loss of health benefits for many working Americans. In 1992, 1,200,000 American families lost their insurance. Many other Americans believed that their current insurance would not be sufficient in the case of a severe illness or injury. The loss of security felt by millions of Americans increased public attention on the health-care system. While many did not want the government to run the health-care system, they believed that the government had to institute some kind of reform.

How the issue was framed
On September 22, 1993, Clinton addressed the issue of health-care reform to a publicly-broadcast joint-session of Congress. The speech outlined a plan for universal health coverage. He made the case for reform by citing rising health-care costs, 37 million uninsured Americans, and a generally wasteful and inefficient system. He outlined the proposal within the context of these six principles: security, simplicity, savings, choice, quality, and responsibility.

Much of the speech was devoted to the idea of prevention &mdash; the long-term benefits of more preventative care &mdash; and cutting the financial burden of universal coverage. Clinton depicted the current system as barring doctors from working effectively, and individuals from the right care. He conceded that his plan would cost more for some, but stressed that everyone would save in the long term. He asserted that there should be no free rides in the US health-care system; everyone should pay. Clinton posited universal health care as his generation's "moon landing", and as a step towards the equality of public welfare.

Policy communities
First Lady Hillary Rodham Clinton played an important role in the formation of health policy. She took health policy to be her "crusade" and stood by her husband and spoke at Congress, advocating the passage of new health-care reform. On January 15, 1993, it was announced that Hillary would be in charge of a task force made to develop a plan for health-care reform. Hillary on the Hill became one of those events charged with political symbolism, and unforeseen consequences. It was dramatic. It was triumphant. But its very success also triggered new and intense activity among opponents who saw in this formidable First Lady a foe whose defeat would require their most determined efforts.

In late 1993, Hillary's approval rating for her handling of health-care reform was actually higher than the President's. The public gave President Clinton a 55% rating, while Hillary got a 60% (Schneider). In late February of 1993, three groups from the health-care industry sued the reform task force, claiming that Hillary could not chair a task force since she was not a government employee. Hillary called the suit a "deft political move, designed to disrupt our work...and foster an impression with the public and the news media that we were conducting secret meetings". The suit resulted in the release of 250 boxes of uninteresting task force memos and reports. The task force eventually formulated a plan for health-care reform in late September, a few months past the "100 days" promise of Clinton; the plan became a 1,342 page long bill known as Clinton's "Health Security" plan.

The Health Insurance Association of America immediately opposed the plan. The Association had hired Bill Gradison, a Republican on the House Ways and Means Committee, as its president and chief lobbyist. Gradison brought Charles Kahn, the leading health-policy counsel on Ways and Means, on board as well. Gradison then initiated a $3 million ad campaign against Clinton's plan. . The most famous ads featured a husband and wife, Harry and Louise, discussing the Clinton plan and using phrases such as, "The government may force us to pick from a few health plans designed by government bureaucrats" and, "government monopoly". The advertisements may have been particularly effective because they characterized Clinton's plan as being in conflict with middle class values. The Health Insurance Association of America also used its own insurance agents to lobby their communities and members of Congress.

This lack of support for a national health-reform plan prompted Aetna, MetLife, Cigna, Prudential, and Travelers to resign from the Health Insurance Association of America in 1992. These five companies formed their own lobby group, the Alliance for Managed Competition, which supported Clinton's plan in some areas, but called for change in others. For example, they opposed the creation of a national health board which could cap health spending nationally.

Policy entrepreneurs
Senator Jay Rockefeller of West Virginia had a personal stake in the passage of health reform because his mother had died of Alzheimer's disease. He took the issue so seriously that "he believed health care reform to be an issue that represented nothing less than the economic health and future of the United States".

Arnold Bennett, the Media Director of Families USA was another key player in the Clinton health-reform initiative. Arnold Bennett is a political activist, Democratic consultant and documentary filmmaker. Bennett said, “is unfortunately not the only report that conveys the notion that the Clinton health reform plan will help the uninsured at the expense of the middle class, and that new taxes on us are needed to insure them”.

Another key player was Senator Ted Kennedy from Massachusetts who strongly believed in health reform and supported Clinton whole-heartedly. He "believed this was a moment of historic opportunity, the most favorable in all his years in Congress" (Johnson and Broder 34).

The national mood
In the initial months of the Clinton Administration, the public had a limited amount of confidence in the new president. Following two failed Attorney-General nominations, a Republican filibuster of the first part of the Clinton economic plan, and a controversy over gay soldiers in the military, the nation was in a skittish mood, but open to health reform.

In one of Clinton's initial polls on health care, most individuals were unhappy with their personal health coverage. Two-thirds of voters were dissatisfied with the overall health-care system. Further, based on the polling data, the administration concluded that the public wanted to see "Congress take its time" in making major changes. Thus, the administration worked to frame their reform as a deliberate, bi-partisan, and inclusive reform process (Johnson and Broder 18). At the time of Clinton's speech to present his plan in September of 1993, one Harris poll found that ninety-one percent of Americans agreed with the idea that, "everybody should have the right to get the best possible care &mdash; as good as the treatment a millionaire gets," and a Gallup poll found that eighty percent of Americans believed that, "government should be responsible for medical care for people who can't afford it" (Yankelovich 12). The only two groups who did not support Clinton's plan were Republicans and many of those who earned more than $50,000 per year (Blendon, Brodie, Benson 9).

The No Name Coalition, started by the Conservative Christian Coalition and National Taxpayers Union placed negative editorials in The Wall Street Journal and, along with other prominent conservatives such as talk-show host Rush Limbaugh, waged an intensive war against Clinton’s plan. In the end, the Coalition grew to include more than 30 organizations. This does not include include additional money by corporations and other associations, public records show that the Coalition spent over $100 million dollars fighting against Clinton’s plan.

Just as Clinton was about to begin a series of speeches and events to generate attention and support for the health-security plan in late 1993, the crisis in Somalia erupted. Two Black Hawk helicopters were shot down in the Battle of Mogadishu; 18 Americans were killed and another 80 were wounded. The nation's attention was captured by the events, causing Clinton to put his plan on hold for an entire month (Quadagno 187).

Organized political support and opposition
Newt Gingrich was one of the staunchest opponents to Clinton and his health-care plan. Only by controlling Congress with a new conservative Republican majority could the final goals of their "Republican Revolution" be achieved: to break the public dependency on Democratic tax-funded government programs; "defund the government," as they put it, and in so doing, destroy the liberal constituency groups; and permit the flowering of an antigovernment, antitax, entreprenurial nations. All these aims were threatened by the Clinton plan. (Johnson and Broder 12) Gingrich attacked the proposal, and claimed it would create "bigger government, bigger bureaucracy and higher taxes for worse healthcare" (Clymer).

Medical lobby communities gave moderate support to the Clinton plan. For example, the AMA supported employer mandates and universal coverage, but did not support reductions in Medicare benefits, caps on spending, or criminal penalties for abuse by physicians. Similarly, the American Group Practice Association (AGPA) supported cost containment and universal coverage, but opposed premium caps and health alliances, fearing interference with group practice strategies (Langbert 642).

Labor union leaders the AFL-CIO favored the Clinton plan initially; they supported employer-based solutions for the health-care problem. (Johnson and Broder) This proved untimely however, as the prospects of an employer-mandated option seemed to be unpopular with business (Gottschalk). In 1993 and 1994, the AFL-CIO staged many grassroots efforts to generate support for reform (Dark). The labor movement "played old politics" through local efforts, while the Republicans and opposers of reform used the media to reach the mass public (Johnson and Broder). Organized labor opposed, most of all, taxation of health-insurance benefits (Langbert 642).

However, strong opposition forces from interest groups and the business class existed. The Health Insurance Association of America spent over $20 million on advertisements to oppose a universal health-reform plan. Their efforts included the notorious "Harry and Louise" television commercials. Other techniques such as mailing campaigns and phoning were used by coalitions.

Moreover, small businesses, which feared financial burdens, organized oppositions with mailings and town meetings (Reynolds). The National Federation for Independent Business (NFIB) fiercely opposed employer mandates &mdash; a crucial component to the Clinton Plan (Starr: 1995). Small business pledged to oppose any legislation with an employer mandate; Clinton's plan had a mandate requiring all employers to pay 80% of insurance premiums. In a 1995 survey, only 28% of companies supported an employer mandate (Martin 899, 904).

On the other hand, big business generally supported employer mandates. According to Michael Becker, vice president of benefits for McDonnell Douglas Corporation, claimed in 1995 that companies with generous benefit programs would experience cost reductions as a result of universal coverage (Langbert 642).

In his first of what would become legendary strategy memos circulated among Republican policymakers, critic William Kristol said the party should "kill," not amend or compromise on, the Clinton health-care plan. He reasoned that allowing any plan to pass under a Democratic president and Congress would give that party control of the middle-class vote. Ideologically, this would encourage and strengthen New Deal liberal ideas of government support, at the cost of gains from limited government. He wrote, It will re-legitimize middle-class dependence for 'security' on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government. (Johnson and Broder 234)

Thus, Kristol presented the first public document uniting Republicans behind total opposition to the reform plan, a position already (privately) advocated by Newt Gingrich and other strategists. A later memo advocated the phrase "There is no health care crisis," which Senate Minority Leader Bob Dole used in his response to the State of the Union Address (Johnson and Broder 270). Unfortunately, this resulted in an avalanche of phone calls from citizens seeking to demonstrate the reality of their health-care problems, and played into the image of Republicans as aloof and uncaring (Johnson and Broder 363).

Kristol was so set on total opposition to any health reform under a Democratic Congress that he urged the defeat of liberal Republican Senator John Chafee's compromise bill in another memo. He wrote, The Chafee-led rump group runs the serious risk of snatching defeat out of the jaws of victory. We're going to defeat Clinton on health care, win seats in November, and pass our own health bill next year. (Johnson and Broder 446) By then, Republican policymakers were so overwhelmed by these weekly memos that they felt they had no choice but to follow in total opposition to reform, not compromise (Johnson and Broder 385). After the death of the plan, Kristol went into the midterm election proclaiming, "I think we can continue to wrap the Clinton plan around the necks of the Democratic candidates." (Johnson and Broder 531)

Why the window of opportunity for health reform opened
In part, public opinion helped open up a new opportunity for health reform during the Clinton era. Beginning in 1973, Americans felt that they had been spending “too little rather than too much on protecting the nation’s health” (Blendon & Benson 38). By 1993, national health spending had reached a record high of $888 billion as health-insurance premiums rose rapidly (CMS). Public confidence in institutional leaders of medicine reached a record low (44%), and a majority of Americans felt that the nation was spending too little on improving health care (Blendon & Benson 38-39). In the 1992 election, voters ranked health care as the third most important issue in their presidential choice, behind only the economy and the federal budget deficit (Blendon, Brodie, Benson 12).

After the hard-fought 1992 election, Clinton stepped into office with fresh optimism and confidence in his abilities. With the American public and an experienced, Democrat-dominated Congress supporting him, President Clinton seemed like the right man in taking on the task of health-care reform. As Clinton began formulation of a national health-care plan, public opinion polls showed a two-to-one margin of approval for the plan; fifty-seven percent of Americans approved of the plan that Clinton was promising (Yankelovich 11). Even as the nation's trust in the presidency and government was falling, Americans became noticeably more supportive of government involvement in health care (Hacker 658). Paul Starr, a sociologist from Princeton and author of "The Middle Class and National Health Reform," claimed that, due to pressures from the middle class, the pressure for national health-care reform was stronger in the 1990s than it had been for decades (Hacker 657).

Why the window of opportunity for health reform closed
President Clinton’s failure started with the isolation of important players, Congressional leaders and administration officers, whose support would be critical in shepherding reforms through Congress. The Clinton Administration tried to tie the health-reform plan to the budget reconciliation bill, but key senators refused to allow such an action. Instead of compromising and reaching out to moderate Congressmen, President Clinton continued to push his own plan. Arrogant, and perhaps hard-headed, President Clinton continued to back his own plan. He further alienated support by pledging to veto any bill that did not provide universal coverage (alternative plans) in his 1994 State of the Union Address (Reynolds). Additionally, Clinton's "closed door policy" surrounding the generation of a health-care reform plan angered both Democrats and Republicans on Capitol Hill. By leaving key decisions to relative outsiders, Hillary Rodham Clinton and top aid Ira Magaziner, President Clinton turned his back on the legislators whose votes he eventually needed (Reynolds).

Moreover, Clinton's leadership style was a hindrance to the passage of health legislation. He was optimistic almost to a fault. Related to Clinton's energy, enthusiasm, intelligence and devotion to policy is a cluster of more problematic traits &mdash; absence of self-discipline; hubristic confidence in his own views and abilities; and difficulty in narrowing his goals, ordering his efforts and devising strategies for advancing and communicating the ends he seeks to achieve (Greenstein 594).

Clinton was slow to pass health reform. During his campaigning, he promised to have a health-care bill ready within the first 100 days in office, but in reality, it took over nine months to prepare the bill. Clinton's failure to mobilize during the "honeymoon period" impeded his ability to get the bill passed. By the time Clinton presented a plan to Congress, more than 500 lobby groups had bombarded the administration on the topic of health reform (Langbert 641). In addition, Clinton took on many responsibilities, impeding his ability to focus solely on health care. This delay played a crucial part in the demise of the reform. It afforded the opposition time to organize and mobilize public opinion against the plan (Reynolds).

This delay itself, was not all his fault. The administration’s health-reform plan was halted for nine months because of concerns about getting the budget reconciliation bill passed. Clinton thought he had enough votes to pass the budget bill, but key senators backed out.

When the bill was finally made public, only twenty-one percent of Americans said they knew a lot about Clinton's plan. One month later, only seventeen percent of Americans felt they knew what Clinton's plan was about. That number fell to thirteen percent one month later (Yankelovich 14). He lacked a concrete plan as well as consideration of the financial costs of such health-care reform. The lack of a definitive plan limited the credibility and therefore the efficacy of the Clinton plan.

The future of health-care reform
One interesting duo paired up to work on health-care reform in 2006; Hillary Rodham Clinton and Newt Gingrich. "As it turns out, Gingrich and Clinton have a lot more in common now that they have left behind the politics of the 1990s, when she was seen as a symbol of the liberal excesses of the Clinton White House and he was a fiery spokesman for a resurgent conservative movement in Washington" (Hernandez).

Although the pairing surprised many people, both Clinton and Gingrich were confident. Clinton stated that, "I find he and I have a lot in common in the way we see the problems that we're going to have to deal with in order to have a 21st-century health-care system." Gingrich also expressed confidence in the bipartisan nature of their effort, saying that, "I'm confident there are things like votes in the Senate and judges where there would be dramatic difference, but I think we're both mature enough as adults that we separate this argument" (Washington Post).

While Bill Clinton was not successful with his national health-insurance initiative, there were several programs enacted during the Clinton administration that expanded Medicaid coverage for select groups, especially low-income children.

Specifically, the Balanced Budget Act of 1997 established both the State Children's Health Insurance Program (SCHIP) and an additional Medicaid coverage group for low-income children parallel to the group of children eligible for SCHIP. The two provisions allowed states to choose to extend Medicaid for targeted low-income children, create a new SCHIP program for those children, or coordinate both programs to cover the target population. Targeted low-income children are those who are not otherwise eligible for Medicaid, not covered under a group health plan or other insurance, and are living in families with income that is either, (1) above the state's Medicaid financial eligibility standard but less than 200% of the federal poverty level; or (2) in states with Medicaid income levels for children already at or above 200% of the poverty level. As of August 2004, 33 states cover targeted low-income children under Medicaid.

A Legal Advocate named Gordon Bonnyman has also used the legal system to try to expand health-care access. Bonnyman is the executive director of the Tennessee Justice Center, an organization that sues Tennessee to force expansion of the state’s Medicaid plan (TennCare). The program has successfully helped 400,000 people receive insurance. Bonnyman still believes however that the best solution to the health-care problems facing this country is to promote universal health-care coverage. While he does not think that a single-payer system could work in this country, he suggests an incremental approach which would force both parties to compromise and to stop waiting to find the "perfect" universal health-care plan. He also believes that a universal health-care plan would eventually save costs.

Jonathan Overland, of Health Affairs journal, lists some political obstacles to health reform. One is institutional fragmentation. The structure of U.S. political institutions creates a number of barriers to the passage of any legislation, let alone a reform as controversial, ideologically divisive and threatening to powerful interests as national health insurance. (Overland 3) He also cites the fact that political parties are weaker in the US than anywhere else in the democratic world. The structure of Congress also establishes an "institutional bias in U.S. politics favoring the status quo: traditionally reformers have had to jump over every legislative hurdle, while opponents have only had to trip them up once to win" (Overlander 3). An unbalanced political arena and the general political culture are also obstacles. He writes that, the three most overlooked lessons from US health politics are these: (1) Getting reform onto the national agenda does not mean that it is going to pass; (2) Consensus that a problem exists implies no agreement whatsoever on solutions; and (3) Favorable public opinion does not guarantee legislative victory. (Overland 8)

After 2001. public attention was put onto national defense and the war on terror. The nation also expressed high concern for the economic status of the country. As time goes on, domestic concerns will get more of the spotlight. Fears of the economic status combined with the purportedly inevitable bankruptcy of Social Security, Medicare, and Medicaid, should give great support for health-care reform.